Since the publication of the IOM reports To Err is Human and Crossing the Quality Chasm there has been a huge increase in QI initiatives aimed at improving the delivery of quality and safe healthcare. Despite this growing attention and activity there is concern that such efforts are not producing sufficient improvements and, although there are many examples of successful QI initiatives there are equally if not more stories of initiatives that have failed to work or to be sustained.

​Contextual factors known to contribute to QI project success include, but are not limited to leadership support, culture, team effectiveness and resources. Several models have been proposed to help organizations assess the degree to which their context is conducive to QI project success. However these models do not significantly address issues related to the recipients of change, that is, point-of-care caregivers and staff.

​​People are not passive recipients of change; their ability and willingness to adopt change is impacted by the intervention design (what they are being asked to do) and the implementation strategy (how they are being asked to do it). Many improvement projects add process steps and tools to existing workflows requiring caregivers to increase their workload activities without being provided with additional capacity. ​

A recent study measured the workload associated with the implementation of the ventilator bundle. Nurses estimated that an additional 115 minutes/ patient/ day were required to complete the ventilator bundle tasks, often resulting in delays of other required patient related tasks. Similar additional workload demands have been seen with blood sugar control protocols and the use of health information technology.

However not all improvement initiatives increase workload. The surgical safety checklist takes about 2 minutes and has been shown to produce a 31% reduction in delays. The ​​creation of a central line bundle cart was seen as essential to the success of this initiative as it reduced delays in obtaining necessary equipment.

If a single improvement initiative can add incremental workload​, then subsequent change efforts can lead to cumulative workload and an ongoing reduction in capacity...a situation that is unsustainable and has shown to result in burnout, change fatigue, introduce workarounds and promote errors. However, if change efforts reduce workload or create capacity then the workflow improves and there is more capacity for ongoing change.

Therefore, given the importance of workload and perceived value, improvement initiatives that do not add additional workload (or reduce workload) and have high perceived value are more likely to be sustainably adopted, cause less workplace burden and, achieve the intended outcomes.

In addition to the issue of workload, people perceive value of change. Perceived value refers to the willingness or readiness for individuals to adopt change when they believe the outcome of the change will be of value to them (or things of importance to them.) Perceived value has been described as having three dimensions: emotional (I want to prevent infections), practical (I can do this change) and logical (this change will lead to less infections). Research in service industries has shown that strategies aimed to increase perceived value in consumers leads to an increase in demand for those services and consumer satisfaction. The issue of perceived value is relevant to change within healthcare. Change initiatives that have high adoption rates have been shown to have higher ratings on value-based factors, including those that are dependent on the design of the intervention/ innovation and those related to the change management strategy used.​